Lessons for the Country from Michigan: How Adult Foster Care Destroyed Adult Foster Care

This is that home today; 40 years later.

I remember being a kid and living near what the neighbors described as a “special house”.  Little did I know it was a group home for the mentally ill.  The 6 male residents hung out on the front porch smoking and tossing cigarettes, sometimes yelling, sometimes napping.  Even as a child I wondered why the home was so unkempt.  I even remember the owner.  She was a tall rather gallant woman who drove a red Cadillac.  One day they were all gone, business closed.

I ran into the owner some years later when I was in the adult day care business.  She explained her home had been under contract with a community mental health agency called RCA or Residential Care Alternatives and that during an audit process some irregularities with how she kept the books led to her losing the contract so she had to close and sell the property.  I recall her blaming everyone in the world including clerical employees who she says were out to take her down.  Unfortunately considering she had gotten away with this behavior for 20 years, you can understand why suddenly she was surprised when certain published guidelines were now being enforced.

Its a story I have heard more than I care to remember from the adult foster care community in Michigan. Its a system with uniqueness like no PIC - FLORIDA DEPT ELDER AFFAIRSother.  In Florida before you can enter assisted living you have to complete what is called CORE Training that has an established, State approved curriculum that covers the clinical and the operational end of the business.  You must then pass a review exam, after which you are issued a card certifying your completion. (Click here for details from the Florida Department of Elder Affairs)

In Michigan you need a high school diploma and one, (1) year of experience working with the population you indicate you plan to serve.  An administrative rule, specifically 400.14201 does specify areas in which you require competency but there is no curriculum approved for that new entry preparedness and no mechanism that ensures the business attracts people with both a quality of life and an earning focus.  A gentleman I know well was deemed qualified to serve as an administrator in adult foster care after previously being a barber in a mental health hospital.  Maybe licensing personnel search for more qualifications these days but no published rule change could be found.

After the 2007-2009 setbacks and budget cuts many providers became really disillusioned.

As frustration grew with serving the mentally ill and those with developmental limitations and mental health budget cuts resulted in unbearable financial setbacks for many adult foster care providers, they turned to serving the elderly and the medically fragile.  This care was typically paid for by the resident themselves.  This was at the same time that Medicaid waivers, specifically the Nursing Home Transition and Diversion Waivers, matured and began paying for residential care in adult foster care homes.  Many group homes were needed and were allowed to enroll as providers but calamity was not far down the road.

Many of these providers had no training in what real contract management is.  They were not accustomed to paperless environments and others had allowed themselves to be lulled into a sense of entitlement.  This sense was directly associated with the mindset of many caregivers who feel the world owes them as a result of how they care for others.  Such a mindset quickly blurs the line in their minds that should remind them they are in fact running a business.

A spirit of complaint grew and grew in many as community mental health agencies tried to manage provider frustration that for the most part grew out of cuts to reimbursements and late reimbursement payments. Of course many also were just not familiar with the dynamic of running a multi-tiered corporation.  This spirit trickled into interactions with resident families including among those who transitioned to different populations so the public perception of the adult foster care provider became even worse.

Business and contract personnel within area agencies on aging and other Medicaid waiver agents quickly became frustrated with adult foster care business owners who:

a.  Did not efficiently manage discharges and admissions

b.  Hired people without proper training and whom they did not properly train after hiring

c.  Hired people whose lack of professionalism from appearance to writing ability turned off resident families

d.  Were focused more on self-enrichment and due to the resulting greed underpaid people which created a substandard care environment

e.  Became unglued at every potential inconvenience which removed a pro-active, sensible approach to problem solving

Many agencies ended up with more people who needed their help and who could be discharged from nursing homes but the waiver agent lacked the capacity to place them in responsibly managed beds.

Case managers have made similar complaints associated with their need to often arrange the best possible accommodations for those injured in a catastrophic auto collision.

Heidi Morton of Lovejoy Rehabilitation (2nd from left) at a 2009 Livonia, MI event

While it is true the State of Michigan could do more to heighten licensee preparedness and competence and perhaps a provider association could offer training in certain business principles, the question for so many is whether or not its too late to make a difference with many who are already in the business.  Of course there are exceptions. Not all providers are substandard.  You run into Janet McCarver of Creative Images, Heidi Morton of Lovejoy Rehabilitation, Milton Kennedy of K & K Assisted Living, Marie Sankeur of A Room at The Inn and others you will find caring, educated individuals who more than qualify to run a group home operation.  Unfortunately in many counties they are the exception, not the rule.  After all when recently recommending a group home to an Oakland County, Michigan hospital social worker, she responded, “please don’t send that vermin to me”; a clear impression left with her from the many adult foster care providers she has encountered.

While ugly speech will not help us to bring about systemic improvements that can create a more responsible and accountable community based care operation,  families surely can come together and demand not only high but monitored and enforceable standards.  A set of national standards issued by the U.S. Department of Health & Human Services could also have appeal and long-range benefits.  Hopefully it would result in Medicare dollars being used in these community based care environments to create more person-centeredness and a less expensive rehabilitative option.

Most would likely agree that the current approach has already crashed and burned. Its not the first time a system such as this has done so.  But it sure rings home when a system does it to itself, over and over again.

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